Fairview Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to track the care of pregnant patients that present to Obstetric Triage seeking care for emergency medical conditions in a central log and the facility failed to perform an appropriate medical screening exam for a patient that presented to the emergency department requesting treatment of a medical condition. See A2405 and A2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to track the care of one patient who presented to Obstetric Triage seeking care for an emergency medical condition. This affected Patient #14. Findings include: Review of the outside medical records of Patient #14 revealed the patient presented to an outside hospital on 07/25/24 complaining of pain from uterine contractions. A nursing note on 07/25/24 at 1:39 PM stated that patient wished to go to another hospital on her own and not wait for transfer and that risks and benefits were discussed by an obstetric physician. Communication notes from the primary OB/GYN’s office dated 07/25/24 at 12:11 PM stated: “Patient is 33.3 weeks pregnant. Started cramping yesterday. Continues today. Does not feel like it is stopping. Rates them 7/10. No bleeding. No leaking of fluid. Positive fetal movement. Patient has two other children. Delivered at 32 weeks and 35 weeks. Due to history, patient advised to report to triage. A communication note at 12:21 PM from the physician stated: “Agree with nurse’s recommendation.” A second physician’s communication note stated Patient #14’s father of baby calling in, very upset about waiting to be seen in triage, states he is taking the patient back to original hospital for evaluation. During an interview on 06/12/25 at 11:59 AM, Staff K recalled the patient. She confirmed that she advised her to go to facility’s Obstetric Triage for evaluation. Staff K explained that as a true generalist physician, she was not working at the facility at the time that the Patient #14 and her significant other called, as she was providing care for patients at a network hospital where obstetric care is not provided. She advised them to go to the facility where obstetric care would be provided. Staff K stated given the SP’s history, the patient’s concerns were taken seriously. During an interview on 06/12/25 at 10:45 AM on 06/12/25. Staff F recalled the patient. She stated she examined the patient and believed she was in preterm labor and should be admitted. The patient, however, wished to deliver at another hospital and decided to leave against medical advice (AMA). The patient called back from the waiting room at the outside hospital. She spoke with the patient’s significant other who stated staff at the outside hospital advised them to return to the original hospital as they were full and it would be a long while before the patient could be examined. The patient’s significant other also stated the office of the patient’s primary OBGYN was called to see if any strings could be pulled to expedite care but there was nothing that could be done. Staff F stated that she advised the patient’s significant other although the outside hospital was required to provide a medical exam, if the patient returned to the original hospital, care would be provided. The patient and her significant other returned to the original hospital where she was admitted and care was provided. Ultimately, the patient was transferred to a tertiary facility within the same network of the hospital that was full. The emergency room log and the Obstetric Triage Daily Log from 07/01/24 through 07/31/24 were reviewed and Patient #14 was not listed on either log during this timeframe. During an interview on 06/12/25 at 9:00 AM, Staff G stated pregnant patients bypass the main emergency department (ED), coming directly to Obstetric Triage from 7:00 AM until 9:00 PM. At 9:00 PM, all hospital doors are locked and pregnant patients must enter the door to the main ED. If the patient has an arrival complaint related to her pregnancy, she uses a phone that calls directly to Obstetric Triage. During an interview on 06/12/25 at 11:25 AM, Staff G stated that patients aren’t listed in the Obstetric Triage Daily Log until they are being seen in Obstetric Triage. As pregnant patients present to Obstetric Triage, their names and arrival complaints are written on a piece of paper and they are directed to the waiting area until a triage room is available. The piece of paper is not maintained beyond that day. There is no way to know if a patient left without being seen. During an interview on 06/12/25 at 2:50 PM, Staff B and Staff H confirmed that a pregnant patient that presented to a dedicated emergency department seeking care for an emergency medical condition was not tracked. The facility policy titled “EMTALA-Central Log Policy”, effective 08/11/16, stated each hospital or free standing emergency department has the discretion to maintain the central log in a form that best meets the needs of its department and patients. The central log should include patient logs from other areas of the hospital such as Behavioral Medicine, Pediatrics and Labor and Delivery, or any other department where a patient might present for emergency medical services or receive a medical screening examination instead of in the ED. All logs must be available in a timely manner for surveyor review. The log must also contain: the name of the individual seeking assistance and the disposition.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to perform an appropriate medical screening exam for a patient that presented to the emergency department requesting treatment of a medical condition. This affected Patient #14. Findings include: Review of the outside medical records of Patient #14 revealed the patient presented to the outside hospital on 07/25/24 complaining of pain from uterine contractions. A nursing note on 07/25/24 at 1:39 PM stated that patient wished to go to another hospital on her own and not wait for transfer and that risks and benefits were discussed by an obstetric physician. Review of communication notes from the primary OB/GYN’s dated 07/25/24 at 12:11 PM stated: “Patient is 33.3 weeks pregnant. Started cramping yesterday. Continues today. Does not feel like it is stopping. Rates them 7/10. No bleeding. No leaking of fluid. Positive fetal movement. Patient has two other children. Delivered at 32 weeks and 35 weeks. Due to history, patient advised to report to triage. A communication note at 12:21 PM from the physician stated: “Agree with nurse’s recommendation.” A second physician’s communication note stated, Patient father of baby calling in, very upset about waiting to be seen in triage, states he is taking Patient #14 back to original hospital for evaluation. The emergency room log and the Obstetric Triage Daily Log from 07/01/24 through 07/31/24 were reviewed and Patient #14 was not listed on either log during this timeframe. There was no medical record for Patient #14 and no documented evidence a medical screening exam was performed. During an interview on 06/12/25 at 9:00 AM, Staff G stated pregnant patients bypass the main emergency department (ED) coming directly to Obstetric Triage from 7:00 AM until 9:00 PM. After 9:00 PM, all hospital doors are locked and pregnant patients must enter the door to the main ED. If the patient has an arrival complaint related to her pregnancy, she uses a phone that calls directly to Obstetric Triage. During an interview on 06/12/25 at 11:25 AM, Staff G stated that patients aren’t listed in the Obstetric Triage Daily Log until they are being seen in Obstetric Triage. As pregnant patients present to Obstetric Triage, their names and arrival complaints are written on a piece of paper and they are directed to the waiting area until a triage room is available. The piece of paper is not maintained beyond that day. There is no way to know if a patient left without being seen. During an interview on 06/12/25 at 2:50 PM, Staff B and Staff H confirmed there was no documentation a medical screening exam was performed for Patient #14 after she presented to a dedicated emergency department for medical treatment. The facility policy titled “EMTALA-Medical Screening Policy”, effective 08/11/16, stated all patients coming to a system hospital or freestanding emergency department requesting emergency services must receive an appropriate Medical Screening Examination as required by EMTALA. When an individual arrives at the ED, and a request is made on the individual’s behalf for a medical examination or treatment, the hospital must provide for an appropriate Medical Screening Examination within the capability of the hospital’s ED or free standing ED to determine whether an Emergency Medical Condition exists, or with respect to a pregnant woman having contractions, whether the woman is in labor. The Medical Screening Examination and other emergency services need not be provided in a location specifically identified as an ED. For example, all pregnant women may be directed to the Labor and Delivery area of the hospital.”